It’s a hot summer afternoon in Begumganj block of Raisen district in Madhya Pradesh, a town built up with homes and shops. Inside the civil hospital’s dysfunctional paediatric intensive care unit that houses baby warmers turned upside down, and mattresses used just the day before for sterilising men, a handful of women are holding a meeting.
These are accredited social health activist (ASHA) workers, and they are exchanging notes on the people they have screened and are now helping to cope with depression. From identifying a pregnant woman to hand-holding her through her term, and ensuring vaccination for the newborn, ASHAs are the foot soldiers of India’s rural public health system.
Through a Memorandum of Understanding (MoU) signed by the State government of Madhya Pradesh with non-profit Sangath, project Empower, now in its third year, has been implemented to train ASHAs to become the first point of contact for people in mental distress. Over the last two years, 462 trained ASHAs have screened 18,000 people for depression, enrolled up to 2,200 patients for counselling, and delivered over 13,000 sessions of therapy across three districts: Raisen, Vidisha, and Narmadapuram.
Vandana Vishwakarma, 37, is one of them. She ‘home delivers’ treatment to 6,000 people, both women and men, and has learnt to differentiate depression from being dukhi (sad) or nirash (despondent). “Every day, for about four hours, 20 days a month, I visit five or six homes, asking about the health of the family,” she says.
The stressors in the village are many: alcohol consumption, men out of work, irregular weather patterns that cause crop disruption. “This leads to tension, fatigue, and dull aches that move across the body,” says Ms. Vishwakarma. “We often normalise responses to adverse situations calling it sadness, but that was before our initiation into mental health training,” she adds.
After the meeting, Ms. Vishwakarma steps out of the hospital, wraps her face and head with a cotton scarf to protect against the heat, and revs the engine of her two-wheeler. About 12 km away in the rural heartland, characterised by kuchha roads and verdant fields, is Mundla Chhawal village. She is going to check on Rishika, 23, whom she had diagnosed with depression last year.
Ms. Rishika had dropped out of school in Class IX and was married at 17 to someone in the neighbouring village. Last July, she gave birth to a baby. “Within eleven days, he succumbed to pneumonia,” Ms. Vishwakarma recalls, adding that she was worried because Ms. Rishika was holed up in a small room of the family hut, devoid of fresh air or sun.
Ms. Rishika slipped into depression and Ms. Vishwakarma’s training in mental health screening came in handy. “A girl who was earlier full of life just went silent. She stopped talking to anyone and refused to eat for a few weeks, classic signs of depression,”Ms. Vishwakarma says, confidently.For the next six to eight weeks, Ms. Vishwakarma visited her once a week: “I would just go and sit beside her. She would not say a word, but visiting her was important.”
After every session, Ms. Vishwakarma would neatly jot down feedback in her case notes. Her booklet carries basic cues to help her conduct a counselling session; simple empathetic questions like, “How are you feeling? What do you do when you’re feeling this way?”
Slowly, Ms. Rishika started responding. “She even started looking forward to my weekly check-in visits and started opening up,” she says.
Today, Ms. Rishika engages with life and the people around her. “Vandana didi convinced me to engage myself in activities that would make me happy. Recently, I went to see a play in the nearby village. The mother-in-law’s character was evil, but the daughter-in-law was resilient,” she says, chuckling.
Delivering care at the grassroots
Far from semi-urban Begumganj, psychiatrist Dr. Vikram Patel, Sangath’s founder, who currently serves as professor of global health at Harvard Medical School, U.S., asked himself a question: with the country’s stark dearth of psychologists and psychiatrists, who would be the most competent to deliver basic treatments for the most common mental health conditions?
Results of the national mental health survey conducted in 2015-16 were startling. They found that one in eight or nine Indians suffered from mental health disorders and that 83% of them did not receive any treatment or help. While countries like Germany have anywhere close to 13 psychiatrists for a population of a lakh, India does not have even one psychiatrist per 1,00,000 people, according to data compiled in the Indian Journal of Psychiatry.Most mental health professionals are concentrated in urban centres.
During the same time, Dr. Patel found in field trials in nearby Sehore district that patients who received six sessions of talk treatment showed a positive clinical response that was long lasting. The effects sustained at the end of a year, and a five-year follow-up still showed benefits. He realised that people living in rural areas were the most deprived of mental healthcare.
He turned the model of psychiatric care on its head by taking it to the doorsteps of people who need it the most. “In an acute episode of depression (like that of Rishika’s), studies have shown that taking medication (antidepressants) and simple, but evidence-based forms of talk therapy are both effective, but over the longer term, talk therapy outperforms medication in keeping people well,” Dr. Patel says.
Where few psychiatrists tread
People like Ms. Rishika recuperate from episodic depression and get by with hand-holding from ASHAs.But 27-year-old Sita (name changed to protect identity) was different. Last year, on her daily rounds, the local ASHA worker of the Silwani block, Shobha Verma, became concerned about Ms. Sita’s insomnia. “She would not sleep for days on end, shout, and be seen on the streets in her blouse and petticoat,” Ms. Verma says.
Ms. Sita’s family thought she had been possessed by spirits. In folk parlance, anuppari chakkarwas involved. But Ms. Verma coaxed them to give her some time with Ms. Sita.
She ran a screening test for depression: a patient health questionnaire (PHQ-9), gently nudging her to answer nine questions, including to what extent she felt there was a loss of interest in pursuing her daily routine, how her appetite was, and her interactions with people. In the end, Ms. Verma slipped in a critical question that was crucial to the screening. It involved asking her subtly if she had any thoughts of self-harm.
Dr. Patel explains that PHQ-9 is widely used to screen for depression. Totalling scores for the responses, Ms. Verma found that Ms. Sita had scored a 15, pointing to moderately severe depression. Anything above 19 is severe depression. In addition, “Sita showed signs of psychosis, and I needed to refer her to a psychiatrist,” she says. She sat down with Ms. Sita and her husband, and over many counselling sessions convinced them to see one in Jabalpur, almost 200 km away, the closest city that would have one.
Ms. Sita, who is now pregnant with her fourth baby, says Ms. Verma’s support helps her get by, one day at a time. She fishes for her psychiatric medication in a basket that also has her pregnancy staples: iron, vitamins, and calcium tablets.
Dr. Patel says, “For severe mental health conditions, like schizophrenia, bipolar disorder, psychosis, medication has robust effects when combined with the human element of counselling.”
The programme is now facing a challenge. ASHA workers across Madhya Pradesh — all 65,000 of them — have stopped work and have been protesting low wages over the past couple of months. At ₹2,000 a month, their pay is lower than that of a daily wage labourer. In Raisen, the women have been camping outside the local tehsil office and chanting angry slogans.
“Mama tera kaisa shashan, ASHAaon ka kha gaye ration(How unfair is your legislation, Chief Minister; your government is eating away at our ration).” Madhya Pradesh Chief Minister Shivraj Singh Chouhan goes by the monikerMamaor maternal uncle. The slogans only get angrier. “Darte nahi hai hudki se; Sarka denge khursi se(We do not fear threats; we will uproot you from power).” Poll dates for the State election are expected to be announced for later in 2023.
In this pilot implementation project of Empower, Dr. Anant Bhan, the project’s co-lead, says trained ASHAs are being paid incentives for screening and counselling people at ₹100 per session. They receive separate incentives ranging from ₹10 to ₹1,650 for filling screening forms, orientation, refresher training, and more. These are being paid from the project funds (nearly ₹3.5 crore for the first two years).
“The project is scheduled to end after a year, so we are scoping for additional funding and also hoping that the State health department will absorb the project, scale it up, and embed it within the government framework for larger dissemination and uptake through all ASHAs,” he adds.
Vishwas Sarang, Madhya Pradesh’s Minister for Medical Education, says the State government may consider making trained ASHAs master trainers. They can train more ASHAs, to institutionalise the process.
Faith, hope, and healing
Last month, Ranu Chandrawanshi, an ASHA worker, trained in screening patients for schizophrenia in Amlaha village of Sehore district, woke up to a commotion. Her 40-year-old neighbour Omprakash had become uncontrollably aggressive. “I remember the horror on his children’s faces as he became violent,” she recounts.
Mr. Omprakash has been scarred by frequent road accidents on the highway, where his tea stall used to be. Dragging the injured or the dead to the side of the road had become almost routine for him. “This led to a lot of tension,” he says.
Through her training Ms. Chandrawanshi has learnt that “these are classic symptoms of psychosis and mania”. But Mr. Omprakash and his family believe he is possessed by a spirit. They take him to a local faith healer.
In the nearby village of Bishan Kheda, Hemraj Jagannnath sits on a pedestal in an orange dhoti and a marigold garland, swaying while loudly mumbling a mantra. Mr. Jagannnath, who is also known as Baba Baawan Veer, is a popular faith healer in the area.
A woman has brought her eight-year-old granddaughter with a disability in her leg to see the baba. Mr. Jagannnath sprinkles some ‘holy’ water, waves a peacock feather fan over her, and assures them that all will be well. Villagers stand in a queue, some with offerings of wheat, others with money, waiting to see him.
Dr. Patel has tried to ensure that the ASHAs in villages inspire the same degree of faith as traditional ‘healers’ do. Mr. Omprakash says he will do both. He has agreed to see a psychiatrist at the Sehore district hospital after repeated nudges from Ms. Chandrawanshi.